Non-Suicidal Self-Injury: An Introduction

E. David Klonsky
Stony Brook University

This issue of Journal of Clinical Psychology: In Session is devoted to the

assessment and treatment of non-suicidal self-injury (henceforth self-
injury). In this introductory article, the author describes the scope of behav-
iors referenced by the term self-injury, establishes the historical and current
relevance of self-injury for clinical practice, and summarizes the articles
that appear in this issue. Self-injury is the intentional destruction of body
tissue without suicidal intent and for purposes not socially sanctioned.
This issue addresses many aspects of self-injury, including its prevalence,
functions, assessment, and treatment. The articles feature case illustra-
tions and treatment recommendations, and all have direct implications for
clinical practice. © 2007 Wiley Periodicals, Inc. J Clin Psychol: In Session
63: 1039–1043, 2007.

Keywords: self-injury; self-mutilation; deliberate self-harm; psychotherapy

Self-injury is defined as the intentional destruction of body tissue without suicidal intent
and for purposes not socially sanctioned. Many other terms have also been used to refer
to this behavior, including non-suicidal self-injury (Muehlenkamp, 2006), deliberate self-
injury (Klonsky, 2007), deliberate self-harm (Gratz, 2003), and self-mutilation (Nock &
Prinstein 2004, 2005). Although the term self-injury is used throughout this issue for the
sake of brevity, we use the term non-suicidal self-injury in the issue’s title to emphasize
the distinction between suicide attempts and the non-suicidal forms of self-injury exam-
ined in the present issue.
In this introductory article, I describe the scope of behaviors referenced by the term
self-injury, establish the historical and current relevance of self-injury to clinical practice,
and summarize the eight following articles.

Correspondence concerning this article should be addressed to: E. David Klonsky, Department of Psychology,
Stony Brook University, Stony Brook, NY 11794-2500; e-mail: E.David.Klonsky@stonybrook.edu

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 63(11), 1039–1043 (2007) © 2007 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20411
1040 Journal of Clinical Psychology: In Session, November 2007

Scope and Prevalence of Self-Injury

Common forms of self-injury include cutting, burning, scratching, and interfering with
wound healing. Other forms include carving words or symbols into one’s skin, banging
body parts, and needle-sticking. By contrast, behaviors associated with substance and
eating disorders—such as alcohol abuse, binging, and purging—are usually not consid-
ered self-injury because the resulting tissue damage is ordinarily an unintentional side-
effect. In addition, body piercings and tattoos are typically not considered self-injury
because they are socially sanctioned forms of cultural or artistic expression. However,
the boundaries are not always clear-cut. In some cases behaviors that usually fall out-
side the boundaries of self-injury may indeed represent self-injury if performed with
explicit intent to cause tissue damage.
The prevalence of self-injury is high and probably increasing among adolescents and
young adults. As detailed in the practice-friendly research review in this issue, prevalence
rates are particularly high in community samples of adolescents and young adults, where
between 14% and 17% have self-injured on at least one occasion (Ross & Heath, 2002; Whit-
lock, Eckenrode, & Silverman, 2006). Rates were even higher in a recent, large-scale study
of 9th and 10th grade students (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007).
Historically, self-injury was regarded as a severe manifestation of mental disorder.
For example, many viewed self-injury as a chronic condition that, like schizophrenia,
required intensive inpatient treatment (Graff & Mallin, 1967). Efforts to clarify the scope
and nature of the behavior increased in the 1970s (Carr, 1977; Lester, 1972), and in the
1980s, self-injury was included in the Diagnostic and Statistical Manual of Mental Dis-
orders, Third Edition (DSM-III; American Psychiatric Association [APA], 1980) as a
symptom of borderline personality disorder (BPD).
Almost 30 years later, the status of self-injury in the official psychiatric nosology has
not changed: DSM-IV-TR (APA, 2000) regards self-injury as a symptom of BPD. Although
research findings are consistent with the notion that self-injury is an important symptom
of BPD (Simeon et al., 1992; Zlotnick, Mattia, & Zimmerman, 1999), self-injury can be
found in many other diagnoses as well, including substance disorders, eating disorders,
posttraumatic stress disorder, major depression, and anxiety disorders (Haw, Hawton,
Houston, & Townsend, 2001; Zlotnick et al., 1999). Indeed, it has become apparent that
self-injury occurs even in nonclinical and high-functioning populations such as second-
ary school students, college students, and active-duty military personnel (Klonsky, Olt-
manns, & Turkheimer, 2003; Whitlock et al., 2006).
Although self-injury is less pernicious than previously thought, the high rates are
still alarming. Even in nonclinical samples, self-injury is associated with a variety of
mental health problems including anxiety, depression, and suicidality (Andover, Pepper,
Ryabchenko, Orrico, Gibb, 2005; Klonsky et al., 2003). The increasing prevalence of
self-injury suggests that clinicians are more likely than ever to encounter the behavior in
their clinical practice.

This Issue
It is important that practitioners have access to the latest information regarding the assess-
ment, treatment, and mental health implications of self-injury. It is my hope that this issue
of the Journal of Clinical Psychology: In Session disseminates this crucial information
and guidance to psychotherapists and psychotherapists-in-training.
As a starting point, Jennifer Muehlenkamp and I (pp. 1045–1056) provide a practice-
friendly review of research on self-injury. The review organizes decades of studies so
that practitioners have easy access to information about who self-injures, why people
Journal of Clinical Psychology: In Session DOI 10.1002/jclp
 Non-Suicidal Self-Injury: An Introduction 1041

self-injure, and which treatments are effective for self-injury. The review also clarifies
the relationship and distinctions between self-injury and suicide, as well as psychological
variables most likely to give rise to self-injury.
Barry Walsh (pp. 1057–1068) presents superb recommendations regarding the clin-
ical assessment of self-injury. Effective treatment is facilitated by an accurate and thor-
ough assessment of self-injury and related variables. However, few if any measures of
self-injury have well-established clinical utility. Barry describes the instruments that do
exist, and more importantly, provides guidelines for assessing clients who self-injure
while fostering rapport and a strong therapeutic alliance.
Nira Nafisi and Barbara Stanley (pp. 1069–1079) provide expert guidance on main-
taining a positive therapeutic relationship throughout the course of treatment with self-
injurers. This subject is particularly important because many psychotherapists and
psychotherapists-in-training experience strong feelings in reaction to their client’s self-
injury, such as disgust or blame, that jeopardize the therapeutic relationship and client’s
well-being.
The next four articles each describe methods for treating self-injury and use case
studies to illustrate the respective approaches. Matt Nock and colleagues (pp. 1081–
1090) focus on treating child and adolescent self-injury, as self-injury occurs dispropor-
tionately in these populations as compared to adults. Matt is a leading expert on self-
injury specifically and child/adolescent psychotherapy generally; thus, his article presents
state-of-the art knowledge. Next, Kim Gratz (pp. 1091–1103) addresses emotion regula-
tion treatments for self-injury. Frequent and intense negative emotions are common in
individuals who self-injure, and self-injury is often performed to temporarily alleviate
these negative emotions. Thus, it is not surprising that treatments known to improve
emotion regulation skills, such as dialectical behavior therapy, show promise for reduc-
ing self-injury. Kim, a leading researcher and practitioner of emotion regulation thera-
pies, describes the rationale and successful implementation of treatments for self-injury
that target emotion dysregulation.
Ken Levy and Frank Yeomans (pp. 1105–1119) describe psychodynamic treatments
for self-injury. For many disorders, cognitive or behavioral treatments have been more
thoroughly studied in controlled trials than psychodynamic treatments. However, Ken
and Frank are involved in one of the most ambitious and rigorous studies of
psychodynamic therapy to date, and are therefore ideal choices to share the promise
of psychodynamic therapies for self-injury. Laura Brown and Tracy Bryan (pp. 1121–
1133) provide a feminist perspective on the treatment of self-injury. Some women who
self-injure have histories of physical or sexual abuse that figure prominently in their
treatment. Laura and Tracy give an excellent, user-friendly illustration of how feminist
therapy can help such clients.
Finally, Janis Whitlock, Wendy Lader, and Karen Conterio (pp. 1135–1143) examine
an emerging phenomenon with profound implications for treating self-injurers: the pro-
liferation of self-injury content on the Internet. Hundreds of self-injury message-boards
and Web-logs can be found on the Web, as can thousands of self-injury images and, more
recently, dozens of self-injury videos on YouTube (www.youtube.com). Janis and col-
leagues characterize the nature and extent of self-injury content on the Web, and relate
how this material impacts the course and treatment of self-injury.
Self-injury is a complex, multidetermined behavior, and we still have much to learn.
At the same time, our knowledge about self-injury and its amelioration have increased
dramatically in recent years. I am pleased that this issue provides convenient, practice-
friendly access to this knowledge, and thereby helps psychotherapists do what they do
best: alleviate suffering and improve the lives of their clients.
Journal of Clinical Psychology: In Session DOI 10.1002/jclp
1042 Journal of Clinical Psychology: In Session, November 2007

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 Non-Suicidal Self-Injury: An Introduction 1043

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